Week 2-Psychiatric history Flashcards
What are the 4 components of a psychiatric assessment?
1) Psychiatric history
2) mental state examination
3) physical examination
4) risk assessment
What is involved in diagnostic formualtion of a psychiatric patient?
1) Description of the patient
2) Differential diagnoses
3) Aetiology
4) Management
5) prognosis
What is the purpose of the psychiatric history?
1) Gather information on psychological and physical symptoms
2) Understand the impact of symptoms on the patient’s life
3) Understand the context of the patient’s problems from a psychological and social point of view
4) contributes to risk assessment
5) contributes to formulation
6) provides therapeutic intervention
In what ways is the psychiatric history different to a standard history?
Psychiatric history is longer in length and time to complete with a number of sections.
You may not be able to gather all info in one sitting and may need to fill gaps from other sources e.g. collateral and notes
What should you consider when taking a psychiatric history?
1) Setting, quite and private
2) Build a rapport and be flexible
3) Time constraints
4) Safety –> alarms, patient not between you and the door, inform colleagues where you are, who you are seeing
What is building a rapport about?
Building a rapport is about building trust and a therapeutic relationship
What should you consider when trying to build a rapport?
What are key skills to use here?
Treat patients with respect, empathy and sensitivity.
Think about your 1) body language 2) eye contact 3) phrases and language used.
Key skills:
Active listening (e.g. nodding, acknowledgement (yes, okay, reflections, summarising).
Encouragement : tell me more about that
Validation : I appreciate this must be really difficult to talk about
Appropriate use of silence
Why is building a rapport important especially with the psychiatric patient?
- It may be the first time they’ve built the courage to talk to someone
- They may need reassurance, and have unrealistic beliefs/ unhelpful beliefs of what may happen to them
- They may have experienced stigma when talking about MH in the past
- They may feel isolated (the only one to exp. these sx)
- They are talking about personal and painful feelings/ experiences
- May be concerned about the impact of discussing sx on work/ relationships
What are the components of an introduction in a psychiatric hx?
- Introduce yourself and explain purpose of the interview
- Explain how long the assessment is likely to take
- Explain need to take notes
- explain any cofidentiality issues
- Gain the patient’s consent to speak to informants
Describe the structure of the psychiatric history
- Personal details
- Referral details
- Hx of presenting complaint
- past psychiatrix hx
- past medical and surgical hx
- drug hx and allergies
- family hx
- social hx
- personal hx
- substance and alcohol hx
- forensic hx
- premorbid personality
What are the key personal details you need in a psychiatric hx?
- Name
- Age
- address, type of accomodation
- occupation
- marital status
What are key details of referral hx you need in psych hx?
- Record place and time pt seen
- Voluntary or detained under MHA?
- source of referral
- reason for referral
- informants name and relationship to the patient
What are key details of the presenting complaint?
- Patients own words
- may be appropriate to record problems as described by the informant
- Brief description
Key factors in the hx of presenting complaint?
- Can use similar structure to physical sx (SQITARPS/SOCRATES)
- Site/ Quality –> nature of symptoms
- Intensity –> impact
- Timing –> onset, development, duration, frequency, course
- Precipitating or exacerbating factors
- Relieving factors
- Associated sx
- Explore relationship between psychiatric symptoms, physical symptoms and social problems
- Current treatment and effect
- Previous episodes
- Previous treatment and effect
How would you explore the presenting complaint of a patient hearing voices?
- Onset –> When did they start? Are they there all the time or only certain times? Have they changed since they first began?
- Site –> are the voices in your head or do you hear them through your ears?
- Quality/ intensity –>
- How many voices are there?
- Are the voices male or female?
- do you recognise the voice?
- Do they speak directly to you, about you or give a running commentary?
- What do they say?
- do they tell you to do anything? (command hallucinations)
- do they stop you from doing anything
- Associated symptoms –> tactile or visual hallucinations, delusions, thought insertion/ withdrawal/ broadcast, feelings or reference, low mood?
- Relieving factors?
What are the uses of open vs closed questions?
Open questions:
Enable patients to describe things in their own words
Helpful for the presenting complant and understanding the patients attitude and feelings
Closed questions:
Gain specific info
Focus the patient
What should you not be afraid to ask during the psychiatric history?
Do not be afraid to ask about suicidal ideations and self harm.
Essential to the psy hx and risk assessment
How could you ask about suicidal ideation/ self harm during the psychiatric history?
“How do you feel about the future?”
“Some people when feeling low have thoughts about ending their life. Have you had any thoughts like this”
What do you need to ensure you gain during the psychiatric history?
Explore thoughts and intent when it comes to self harm/ suicial ideation
Establish any past history of suicide attempts and deliberate self harm
What are key components of the past psychiatric history?
- Any current/ previous diagnoses
- Previous episodes
- Previous contact with health professionals
- Previous psychiatric admissions
- Previous treatment
- History of deliberate self harm and suicide attempts
What are key components of the past medical history?
- Any physical illnesses
- Previous accidents or head injuries
- Previous admissions to hospital
Key components of the drug history on psy history?
- Prescribed medications
- OTC medications
- Allergies
- Always confirm with the GP
What are the key components of the family history during the psychiatric hx?
Fam hx:
- Any history of psychiatric illness?
- Any history of suicide?
- Substance or alcohol misuse?
- History of neurological disorders or relevant physical illness?
- Quality of relationship between pt and family members?
Key components of the social history in the psychiatric hx?
- Marital status?
- children and dependents?
- Housing situation
- Employment?
- Finanical problems or debt?
- Social network or support?
- Religious beliefs
What 4 areas of a personal history do you need to explore during psychiatric hx?
Infancy and early childhood
Later childhood and adolescence
Occupational history
Psychosexual history
What elements of infancy and early childhood should be explored?
- Pregnancy and birth complications
- neonatal illness
- developmental milestones
- childhood illnesses
- behaviour
What elements of later childhood and adolescence should be explored?
Childhood family environment
history of abuse (if app)
Education
Bullying
Behaviour
What elements of occupational hx should be explored?
Jobs
Level of satisfaction
Ambitions
What elements of the psychosexual history should be explored?
Relationships
First experiences
Orientation
Marriage hx
Domestic violence
Sexual dysfunction / fetishes (if app)
What elements of substance/ alc hx should be explored?
Evidence of abuse of dependency?
Impact on patients life and relationship between pts problems and drug/ alc abuse
Always ask about cannabis specifically
Think about abuse of prescribed medications (e.g. benzo)
Smoking hx
What elements of forensic hx should be explored?
Previous contact with the police
nature of offences
convictions and imprisonment
name of probation officer and requirements of probation
Hx of violence?
What elements of premorbid personality should be explored?
Patient’s personality before the onset of their mental illness
e.g. if we’d met 5 yrs ago what would you have been like?
When you are well how would you describe yourself/ how would others describe you?
Collateral hx
Also explore –> interests/ hobbies/ relationships/ attitudes
